ECT in Pregnancy-Fetal Heart Rate Monitoring

Out on Pubmed, from clinicians at the University of Arkansas, is this study:

Continuous Fetal Monitoring During Electroconvulsive Therapy: A Prospective Observation Study.

Rabie N, Shah R, Ray-Griffith S, Coker JL, Magann EF, Stowe ZN.Int J Womens Health. 2021 Jan 6;13:1-7. doi: 10.2147/IJWH.S290934. eCollection 2021. PMID: 33442300 

The abstract is copied below:Objective: The use of electroconvulsive therapy in pregnancy has been limited by concerns about its effects on fetal well-being, despite limited evidence that suggests it is safe and effective. No studies have utilized continuous fetal heart rate monitoring during electroconvulsive therapy sessions. We aimed to describe the fetal heart rate patterns of patients undergoing electroconvulsive therapy.
Design: This study is a prospective case series of pregnant patients undergoing electroconvulsive therapy with continuous fetal heart rate monitoring.
Setting: University-based hospital.
Population: Pregnant patients with a psychiatric indication for electroconvulsive therapy.
Methods: Patients underwent fetal heart rate monitoring immediately prior, during and immediately after ECT therapy.
Main outcome measures: Characterization of the fetal heart rate tracing.
Results: Five subjects underwent 44 electroconvulsive therapy sessions. Continuous fetal monitoring was performed on 34 of the sessions. Transient fetal heart rate decelerations occurred in 4 sessions, all self-resolved and none required intervention.
Conclusion: This case series is the first to report the results of continuous FHR monitoring during electroconvulsive therapy. The most common finding was a transient, self-resolving bradycardia that was not associated with adverse perinatal outcomes. This supports the opinion that electroconvulsive therapy is a safe treatment option in pregnancy in women with severe mental disease.

The pdf is here.

And a table:

And from the text:

Conclusion Pharmacotherapy and psychotherapy will remain as the primary treatments for mild mental disorders, such as mild depression and anxiety in pregnancy. Although ECT is often reserved for acute suicidal ideation or severe refractory depression and bipolar disorder, our study supports ECT as a safe treatment option for mood disorders in the perinatal period. Furthermore, continuous FHR monitoring can be logistically challenging and labor intensive, and our study suggests that there is no additional benefit to continuous FHR monitoring. Additional studies could incorporate more patients and add to the available data of FHR monitoring during ECT.

This study adds welcome data to the evidence base of the safety of ECT during pregnancy. While it reports on only 5 patients, pregnant ECT patients are rare enough that this is a meaningful contribution. The good news here is that the fetal decelerations were not dangerous and required no intervention; continuous FHR was not found to confer additional benefit; therefore the recommendations for before and after procedure monitoring listed in the table above.

A couple of aspects of the article deserve comment: the authors report a few very long seizures with large discrepancies between motor and EEG- I suspect poor EEG monitoring and/or interpretation may be the culprit here; also, all of the ECT is right unilateral---very seriously ill pregnant patients may be candidates for bilateral ECT to maximize the likelihood of quick and definitive response. Finally, the stimulus dosing details are not provided, and the inconsistent anesthesia medications are the typical result of rotating anesthesiologists. 

This report should be read in full by all ECT practitioners (~15 minutes).

ECT for postpartum depression and psychosis is an important related topic.